New Hampshire's mental health system: From leader to failure

The main building of the former New Hampshire Hospital is reflected in the window of the Twitchell House porch where Bert Shaw sits while on a break. Shaw is one of the 15 residents of Twitchell, a group home for people with serious mental illness.

(ANDREA MORALES / Monitor staff)

Twitchell house program director Ruby Van Loan hands Bert Shaw his glasses after helping him clean up the lenses a bit while at the living room of the residential program. Shaw was waiting for the bus that takes him to his Riverbend-run day program Step Up.

(ANDREA MORALES / Monitor staff)

Bert Shaw plays a bell while singing with Julieann Hartley, a board certified music therapist, while at Step Up, a day program run by Riverbend that Bert attends every day.

(ANDREA MORALES / Monitor staff)

The main building of the former New Hampshire Hospital is reflected in the window of the Twitchell House porch where Bert Shaw sits while on a break. Shaw is one of the 15 residents of Twitchell, a group home for people with serious mental illness.

During his 1971 inaugural address, then-Gov. Walter Peterson identified seven goals for his next term. First on the Republican’s list was improving mental health care.

Peterson wanted to stop warehousing people with mental illness at the state’s psychiatric hospital and begin treating them in local communities. “A state mental institution,” Peterson told lawmakers 42 years ago, “is, more than anything else, a symbol of failure to help people in time.”

Two decades later, the state had become a national leader in mental health care by beginning what Peterson had envisioned. Lawmakers had established 10 community mental health centers and put money into local housing and local treatment. And under the leadership of then-Gov. John H. Sununu, the state had opened a modern 316-bed state hospital in place of the 19th-century-era institution, once called the New Hampshire Asylum for the Insane, that had housed nearly 2,000 people.

At the time, Donald Shumway, then director of the state’s Division of Mental Health, said the national recognition showed “our plan is really heading in the right direction.”

The acclaim would be short-lived.

Today, everyone from mental health advocates to lawmakers to Gov. Maggie Hassan describe the state’s mental health system as broken.

In a scathing 2011 critique, the federal government said mental health care here is “in crisis.” Federal officials accused the state of violating the Americans with Disabilities Act by starving the community care system in favor of unnecessary hospitalization. Last year, several patients made the same allegation in a federal lawsuit against the state that the federal government has joined.

Meanwhile, people in crisis languish in emergency rooms, sometimes for days, waiting for a hospital bed. The state’s jails and prisons have become the new mental health “‘asylum,” with an estimated 65 percent of the state prison population having a mental illness, according to a prison spokesman.

Many community hospitals have closed their own psychiatric wings. And the 10 community health centers that once brought the state honor, have cut, not expanded, services in the 20 years since the National Alliance for the Mentally Ill ranked New Hampshire so highly.

In her budget address last month, Hassan ticked off these failings and asked lawmakers for $28 million over two years to begin resuscitating community mental health services. It’s uncertain how the Legislature will respond, especially given that Hassan proposes to find the money by counting on revenue from a casino.

But like Peterson did 42 years ago, Hassan sounded a moral note in her assessment of mental health services, saying, “We are not that kind of state.”

How, then, did New Hampshire get so off course?

‘Whipping boy’

There are two culprits, according to mental health advocates in the state, and they are inextricably linked: money and awareness.

“I think there have been competing needs” in shrinking state budgets, said Michael Cohen, who until 2011 was the executive director of the state chapter of the National Alliance on Mental Illness. “And the question has been which of the needs is going to be a priority. And I think for too long the mental health system, unfortunately, has been the whipping boy.”

Asked why, Cohen responded, “I think it’s a value issue . . . and a lack of knowledge, to some extent, of an understanding of what the impact of serious mental illness is on families and the communities.”

Yet Cohen is likely correct when he says everyone knows someone with a mental illness.

According to a 2010 study by the New Hampshire Center for Public Policy Studies, 26 percent of the state’s adults, more than 253,500 people, have a mental illness. A study that same year by the National Alliance on Mental Illness estimated that 43,000 of those adults suffer serious mental illness. The majority of those adults seek treatment at a mental health clinic or from community services, according to the report.

Hassan is not the first to ring the alarm.

Even as the national advocacy group ranked New Hampshire tops in mental health care in its 1990 report, it expressed concern about the state’s future. Then-Gov. Judd Gregg had ordered 9 percent budget cuts for state personnel to balance the state budget.

“The question facing the mental health system in New Hampshire,” the report’s authors wrote, “is whether it will be able to maintain existing levels of service and continue to improve and expand in the face of what is likely to be continuing pressure to cut budgets.”

The answer to that question is undisputed.

Steady erosion of services

Dennis MacKay is the chief executive officer of Northern Human Services, one of the state’s 10 mental health centers. It provides mental health and development care in the state’s three most northern counties, and like the other centers, contracts with the state. The centers rely on Medicaid money for 60 percent of their budgets, with the state covering about 20 percent and the rest paid by Medicare or private insurance.

“What has happened in the North Country is similar to what has happened elsewhere in the state,” MacKay said. “There has been a gradual shrinking of resources. There just seems to be a constant drip out of resources.”

In December, Nick Toumpas, commissioner of the state Department of Health and Human Services, announced he would ask for an additional $10 million in his budget to expand community mental health care. And for the first time in years, the state hospital would add 12 beds to shorten long waits in emergency rooms, Toumpas said.

“It is unacceptable,” Toumpas said then, “for someone experiencing a psychiatric crisis to have to wait this long for critical inpatient care – for both the individual as well as their concerned family members.”

If the community mental health system has such boosters, why hasn’t it been nourished?

MacKay and state officials point to two national recessions, the first in the 1990s and the most recent one that began in 2008. In response to both downturns, the state cut its own agency budgets, including Toumpas’s department, which lost millions.

And elected officials also cut the amount of Medicaid given to community mental health centers. Medicaid covers the bulk of the centers’ budgets and pays for treatment, day programs, crisis management and in-home care.

Mental health advocates measure the “shrinking of resources” a number of ways:

∎ Since 1990, the number of state hospital beds for adults and children has dropped from 316 to 130. Meanwhile, the number of yearly admissions has climbed, from 1,358 in 2002 to 2,305 last year.

∎ The state’s community hospitals provide far less psychiatric care today, largely because the amount they receive in Medicaid reimbursement falls short of what it costs to admit and treat a psychiatric patient. Since 1990, the number of mental health beds in community hospitals has gone from 236 to 150, and six hospitals have closed their psychiatric wings altogether, according to the New Hampshire Hospital Association.

∎ The state hospital has also become nearly the only hospital in the state accepting people who require hospitalization against their will. Since 1998, the number of beds for these involuntary admissions at community hospitals has gone from 101 to eight, all of which are at the Elliot Hospital in Manchester.

∎ There remains too little affordable housing in the community for people with mental illness. Between 2010 and last year, 134 people discharged from the state hospital relocated to a homeless shelter, jail or motel, according to records filed in the federal lawsuit.

∎ The beds in group homes for people with mental illness have become even fewer. There were 178 in 1998, according to the community mental health centers. Today, despite an increase in the state’s population, there are 159.

Riverbend Community Mental Health in Concord has had to combine day programs and close peer support centers that were a relatively inexpensive way to provide the mentally ill with day-to-day support close to home. Case managers are taking on more patients because of budget cuts.

“When you take away those things – community hospital beds, mental health center care and the state hospital, it’s a pretty crippling situation,” said Louis Josephson, chief executive officer of Riverbend in Concord. “They are now saying that 30 percent of all people who get into New Hampshire Hospital are being discharged within 24 hours. And in two days, they are back in the hospital.”

A blow to the 10-year plan

In 2008, just as the state was recovering from the recession of the 1990s, mental health advocates and state officials stood together to unveil a 10-year plan for rescuing the community mental health system.

Over the coming decade, the state would add 132 group home beds; increase financial aid for rent in community apartments; increase the number of involuntary-commitment beds outside the state hospital from eight to at least 48; and create a crisis response team in each area of the state to assist people without hospitalizing them.

MacKay helped write it and was optimistic.

“We had the community support and certainly had the support from a number of consumer groups,” MacKay said. “We had a nod from hospitals that it would be helpful. I was feeling we might be able to accomplish some things.”

MacKay recalls Toumpas, who also worked on the plan, telling reporters at a press conference the state was spending its mental health dollars in the wrong place. MacKay said Toumpas agreed with mental health advocates that community mental health care was cheaper and more effective than hospitalizations.

Jay Couture, executive director of the Seacoast Mental Health Center, was on the team too and shared MacKay’s hope – briefly.

“Just weeks after it was released, the entire nation was in recession,” Couture said.

Little of the plan was realized. It’s now the basis of Hassan’s community mental health budget request. That’s been welcome news to leaders of the community mental health centers, although they’d like to see the state invest $38 million - $10 million more than Hassan – in the next two years.

They’ve met with Hassan and described her as empathetic. They’ve said the same about lawmakers who will decide the state’s budget.

But they also know empathy doesn’t pay the bills.

(Annmarie Timmins can be reached at 369-3323, atimmins@cmonitor.com or on Twitter @annmarietimmins.)

By the time Bert Shaw arrived in New Hampshire nearly 10 years ago to be nearer his daughter, he’d been hospitalized 15 times and had had a few run-ins with the police, all a result of his bipolar disorder. Upon moving here, Shaw, 66, had another hospitalization after Main Street merchants – concerned about his behavior as he wandered downtown …

Joshua Knight was alone, had been for hours. He curled up on the mattress on the floor, shut his eyes and tried to block out his memories of the day. Knight, 33, had been handcuffed and dragged out of his basement apartment in Chichester that September day last year. His mother, Carla Northrup, had been crying so hard the police …

Leaning on her cane, a 56-year-old woman made her way to the front of a Concord courtroom to resolve charges of simple assault and disturbing the peace. Her schizophrenia and delusions had, once again, required a call to the police. But this time, instead of being hospitalized against her will, she’d been arrested and given a choice: Face criminal charges …

Folks, please let us not focus on one particular statistic in the article to the exclusion of the main message. Whether 17% or 26 % of adults have a mental health condition ( and I believe Timmons' figure is accurate given the high number of anti-depressant prescriptions alone in this country)... the people with serious mental illness, a smaller subset of this figure- perhaps 10% - are being woefully underserved in NH and have nowhere to turn to. The care they receive- emergency/crisis intervention- is needlessly expensive. Don't shoot the messenger. We absolutely know how to do this better- NH has already compiled ten year plan to remediate these deficiencies, and only need to put it in practice.

rickame wrote:

03/11/2013

While it may be hard to imagine and could be contested that 25% of folks are 'mentally ill.' It is clear that N.H. is no longer any kind of a leader in this area. In fact, a good case can be made that N.H. is now one of the worst places in the country to be suffering from mental health issues regarding access to services. I know this from working in the field and witnessing the dearth of resources available for both adults and children, as well as from personal experience with a child who was in desperate need of emergency support and got some of the most incompetent care at even a private hospital here in N.H. Its really a crime!

Hunter_Dan wrote:

03/11/2013

This article should be titled AMERICA'S mental health system: from leader to failure!

ajmanuse wrote:

03/11/2013

Is this a press release for the mental health lobby? Did the reporter think about potentially asking the question: Are 26 percent of N.H. adults really mentally ill, or is there something else at work here? It seems awfully crazy (pun intended) to think that 1 in 4 people are mentally ill. Perhaps the problem is not with mental illness, but instead with psychologists who are over-diagnosing mental illness. Perhaps the problem is not the alleged illness, but with the drugs prescribed, which tend to magnify the very problems they're supposed to solve. Perhaps the answer is not mental health care, but instead, getting out of mental health care and help people develop some healthy coping mechanisms in their lives?

nhresident_andfather wrote:

03/11/2013

"Perhaps the answer is not mental health care, but instead, getting out of mental health care and help people develop some healthy coping mechanisms in their lives?"
How exactly does one do that if they are mentally ill? Your answer seems to be to ignore the underlying issue and tell people to deal. Your apathy is alarming, and all of your refutation is without basis.
God forbid you or your family suffers from mental illness and need assistance under the current system. You will find out how real this crisis is.

RabbitNH wrote:

03/12/2013

Questioning that 26% of the population is mentally ill is valid.
Least we forget the over diagnosing of kids with ADD? Now we have shrinks coding kids who mouth off as having mild Tourettes.
The Mental Health business can be looked at in some cases as one that treats the symptoms, not the cause. It seems that everything is chemical when diagnosing mental illness, or a mild form of autisim. I definitly think that should be questioned. But we are a pill popping society here in the US. A pill to cure everything from high blood pressure because you cannot change your diet, to pills and surgery for obesity.
Now we drug our kids. Is it a coincidence we have young men who are angry and violent? Could that be because we drug them?

gracchus wrote:

03/11/2013

The latter half of ajmanuse's comment reads like the self-righteous nonsense that emanates from the self-righteous non-church that calls itself the Church of Scientology.